NMTP Newsletter Volume 4, Number 1, April 2000

Index

CMTP DIRECTOR'S COLUMN - Kermit A. Crawford, Ph.D.

CULTURAL CONSIDERATIONS IN CRITICAL INCIDENT DEBRIEFING IN THE AFTERMATH OF A TERRORIST INCIDENT INVOLVING WEAPONS OF MASS DESTRUCTION - Guy O. Seymour, Ph.D.

ANNUAL MEETING ANNOUNCEMENT

NMTP NOTES PUBLICATION SCHEDULE

Nancy Boyd-Franklin to Visit the Boston Area in September

CMTP TO SURVEY ALUMNAE/I

NMTP AT APA 2000

CMTP DIRECTOR'S COLUMN

Kermit A. Crawford, Ph.D., Acting Director, Center for Multicultural Training in Psychology
Director, Urban Institute for Multicultural Mental Health Research,
Boston University School of Medicine

This is my first CMTP Director's column. I am a former intern (MTP'82) and even now, almost eighteen years later, CMTP still feels like home. It's good to be back "home". The vision of CMTP remains as fresh today as it did at its inception. Despite losses and despite challenges, CMTP continues to thrive. I commend the leadership of Dr. David Trimble, Dr. Leon Nix, and the guiding vision and omnipresence of Dr. Guy Seymour. I also commend the skill and commitment of the four former program directors, Drs. Seymour, G. Rita Grant, Herbert Joseph, and Ms. Gisela Morales.

Our vision remains viable today, which is to provide the highest standard of training for interns in the culturally competent practice of psychology. In many ways, in large part due to NMTP, CMTP is a stronger program today than ever before.

Next year's program (2000-2001) will have seven interns, an increase of 2 (+ 40%) from this year. The stipends will increase to $ 18,500 per year (+ 8%), and along with an appointment to Boston University School of Medicine, optional health insurance, dental insurance and other employee benefits, CMTP's benefits are very competitive with comparable programs in the nation. This year CMTP had more inquiries (437) and more applicants than ever before (159). 49 applicants were interviewed and seven were selected through the National Matching Program.

We successfully completed an APA Self-Study and are planning a site visit in June. CMTP, through affiliation with the Massachusetts Department of mental Health, Metro-Boston Office, has established the Multicultural Training Collaborative (MTC). The MTC is a multicultural, multidisciplinary consortium for training in collaboration with the Urban Leadership Program at Simmons College Graduate School of Social Work and the School of Nursing at Northeastern University. CMTP remains affiliated with the Urban Institute for Multicultural Mental Health Research in the Division of Psychiatry at Boston University School of Medicine. In addition to the excellent clinical training, there will be an expanded emphasis on multicultural research in behavioral health and dissertation completion, which is consistent with APA's scientist-practitioner model. Among last year's class of interns, for example, three completed their dissertations during internship. Last year four articles were submitted for review, and two of were published.

The Program will continue to grow and while we have much to be proud of and much to celebrate, we will remain vigilant and steadfastly committed to the mission, vision and promise of CMTP into the next millennium.

CULTURAL CONSIDERATIONS IN CRITICAL INCIDENT DEBRIEFING IN THE AFTERMATH OF A TERRORIST INCIDENT INVOLVING WEAPONS OF MASS DESTRUCTION

Guy O. Seymour, Ph.D., Chief Psychologist, Psychologists In Public Safety; Clerk, NMTP; Former Director, Critical Incident Stress Management (CISM) Team, Atlanta/Fulton County Emergency Management Agency; Co-Director, CISM Team, Atlanta Committee for the 1996 Centennial Summer Olympic Games (ACOG); Former Director of Psychology and Internship Training, Boston City Hospital.

In 1995 President Clinton signed Presidential Decision Directive (PDD) 39 on the United States Policy on Counterterrorism. This PDD was created largely in response to the bombing of the Alfred Murrah Federal Office Building in Oklahoma City in April, 1995. The President stated that "The United States shall give the highest priority to developing effective capabilities to detect, prevent, defeat and manage the consequences of nuclear, biological or chemical (NBC) materials or weapons use by terrorists." It is in managing the consequences of such terrorist activity that critical incident stress debriefing (CISD) takes place. For the first time in American history attention was to be paid to the aftermath of terrorist incidents as these affected persons on U.S. soil. This was taken seriously as the United States prepared to host the world in Atlanta for the 1996 Centennial Summer Olympic Games. With the experience of the 1972 Munich Games and the New York World Trade Center and Oklahoma City bombings in clear relief, the preparations for possible critical incidents were extensive.

As we learned at the bombing of Centennial Olympic Park in Atlanta the next year, however, even a well-trained critical incident team including a cadre of mental health professionals specifically attentive to multicultural needs and well-trained for terrorist activities can be taxed in performing these tasks. The After-Action Report of the Atlanta-Fulton County Emergency Management Agency (AFCEMA), filed after the 1996 Summer Olympic Games, contains reference to the handling of the death notification of Turkish news reporter Melih Uzunyol, who died of a heart attack en route to the bombing site. In conducting this death notification, the AFCEMA Critical Incident Stress Management (CISM) Team was pushed by the fact that the bombing was a world newsworthy event which occurred during the most widely- televised sporting event ever held and which was being given round-the-clock continuous coverage the world over. The news of Uzunyol's death would likely reach Turkey within minutes of the announcement by the hospital in Atlanta that he had died. The CISM Team, handicapped by a language barrier, nevertheless reached out to the wife and family of the deceased by telephone, using another, more senior member of the news service (the Intermediary) who was personally known to the family, and whose voice would be instantly recognized by the widow, conveying authenticity even across the world. Learning from the Intermediary that death notification in Turkey is emotional and yet requires that the widow show restraint, the CISM team, working through the Intermediary, effected the dispatch of a senior executive of the news station, selected by the Intermediary for appropriateness and because he would command respect and show appropriate respect to the widow, and asked him to take his wife with him to be with the widow when the CISM team and Intermediary called the widow at her home. Fortunately while it was still 0300 am in Atlanta it was already 1000 am in Ankara. Yet, even with a team prepared for such an eventuality (and this CISM Team was well-prepared), an error was made in that the CISM team member who was best positioned to effect the death notification was a woman. It worked well anyway because we were able to enlist the senior male figure in the news station in Turkey and his wife, and because we used the senior male on site in Atlanta as the Intermediary. We only learned later when debriefing the Turkish news crew that there had been considerable discussion about how the choice of Intermediary was made and that it caused some angry confrontations among the crew until the process was explained by the CISM team member to the assembled group.

Despite having a large well-prepared cadre (there were sixty members of the ACOG and AFCEMA CISM Teams working together) this team nevertheless had little time. In the three days following the bombing, over seven hundred persons, mostly law enforcement personnel and olympic event/venue volunteers were individually debriefed. In addition, each of the one hundred and ten casualties and the family members and friends of the deceased received both individual and small group debriefings. The planning for the Re-Opening Ceremonies at the Park required that the cultural diversity of the Olympic Family and the international audience be an essential feature of the considerations for managing the consequences of the event. Fortunately the re-opening team included former U.N. Ambassador Andrew Young and the staff of IOC President Juan Antonio Samaranch. They welcomed the input from the CISM Team because of who they were and their experiences in the international arena. Thus, multicultural considerations were among the predominant considerations of tactics and process for the ceremony which was in essence a huge critical incident demobilization or “debriefing”. Because the context was multinational and multicultural, the expectations of caregivers after the bomb were that cultural considerations, indeed cultural competence, would be the norm, and because the planning had been within this context, it was. “You feel so helpless when something like this happens. Just being able to take a stand with others helps. What I loved most about (the re-opening memorial service) was that on one side I had someone from Taiwan, and somebody speaking Arabic behind me and an Atlantan next to me." -- Jan Oglesbee, 40, of Clarkston, Ga., whose 17-year-old son was in the park the night of the bombing. (Go to this web address for scenes from the re-opening http://europe.cnn.com/US/9707/olympic.park.bombing/multimedia/5parkmem.46.mov)

Unlike ACOG, however, most urban targets of terrorism will not be preparing to carry out their mission and business plan and to conduct their usual activities in the multinational and multicultural context. Even in a city as international as Boston, the medical establishment, though world-renowned, does not view its mission in a multinational and multicultural context. As a result, most urban centers find themselves, as did New York City after the World Trade Center Bombing, unprepared to deal with the non-Anglo-American victims of such an incident. Recent training programs for urban centers to prepare for terrorist incidents involving weapons of mass destruction have suffered similarly from a lack of attention to the cultural diversity in their environments. Training has usually employed the emergency medical systems and law enforcement agencies in the target areas and the critical incident teams usually used by them. For the most part these teams still have paid little attention to cultural diversity because emergency medicine and law enforcement maintain the fiction that “everyone must be treated the same,” meaning that everyone will be treated in the manner in which these agencies ordinarily respond to their clientele. While these agencies are beginning to recognize cultural differences, it is well known that in crisis situations people regress to their most over-learned responses. The 1999 Victim Services Summit of the International Association of Chiefs of Police attested to the fact that culturally competent victim service response is a brand new and not very widely adopted phenomenon. Hence it is not unexpected that in the aftermath of terrorist events the first responders are most likely to act as if they have had no training in cultural diversity at all.

Because weapons of mass destruction (WMD) are varied, and new ones are being devised almost daily, it is not possible to plan primarily for the specific medical consequences of their deployment. Rather it is necessary to be prepared to attend to the human needs of those populations found in the path of the toxic plume or dispersal zone of airborne agents and in the geographic after shock circles of explosives. Always assuming that those care facilities in the immediate vicinity will be contaminated, decommissioned and inaccessible or overwhelmed, critical incident planning and management must survey the possibly affected communities in likely target areas in order to begin to build plans for consequence management that take account of the particular cultural and linguistic character of those neighborhoods. In order to “ensure that the United States is prepared to combat domestic and international terrorism in all its forms.” the President directed that, “We shall have the ability to respond rapidly and decisively to terrorism directed against us wherever it occurs....and provide recovery relief to victims, as permitted by law.” Specifically, the President directed that “the Federal Emergency Management Agency shall ensure that the Federal Response Plan is adequate to respond to the consequences of terrorism directed against large populations in the United States, including terrorism involving weapons of mass destruction. FEMA shall ensure that States' response plans are adequate and their capabilities are tested.” Within the definition of whether a response plan is adequate is embedded the idea that all such responses must be culturally competent, that is to say, that the providers of those responses shall have the attitudes, skills and behaviors to work effectively with others who are culturally different from the mainstream. The difference between doing this in psychotherapy, or even in critical incident stress debriefing for other kinds of disasters, is that in the aftermath of terrorism the tendency to blame the victim, especially if the victim is culturally different, is much intensified. Therefore the single most important consideration in conducting such debriefings after a WMD event is that responders must be aware of their own cultural biases and assumptions. The failure to do so lays the basis for not only ineffective critical incident response but also for harmful and additionally traumatizing interactions between caregivers and victims or victim families.

While conducting Critical Incident Stress Debriefings, cultural considerations are best addressed by following these Guidelines:

1.Explain/educate/orient service recipients as to what you are going to do before you do it so that they may assist you. Listen to their suggestions and adopt the point of view that you will do what they want even if it is counter to your own training.

2.Know your limits. Get consultation. It is a greater shame to practise incompetently and to disrespect your client than it is to admit you need help. Your client or his/her family system can help you do your job. Sometimes a more experienced clinician can show you alternatives you might not have thought of on your own or that you would have come to much later.

3.Be aware of your own prejudices and biases. It is out of our blind spots that the most egregious errors are made. We cannot be too vigilant about our assumptions about others. In the aftermath of a WMD event this can lead to dangerous stereotyping and assigning of fault and even lead to people being quarantined unnecessarily and inappropriately, and a vilification of culturally different persons.

4.Respect traditional roles in communication. The intent of CISD is to remove the excess emotion from the memory of the event so as to integrate the traumatic event into the life stories of the victims/survivors by organizing and interpreting the cognitive process and to create meaningfulness from the experience. This is almost impossible if the person must also struggle to rationalize the violations of the cultural mode of communication when they were rendered “Service.”

5.Respect the world view and belief systems of others and be inclusive in sustained service delivery. If, for example the person you are debriefing also wants to include his or her shaman or curandero in the process, it may be more important to accede to that request than to stand on the principle of the debriefing model which holds that debriefings should only be done with the event participants. The rules for a formal debriefing (which do not include non-participants) might best be kept for the formal group debriefing procedure, usually scheduled at a later date.

6.Speak the language requested by your client. If you are assigned a debriefing with a person whose language you do not speak, that may be acceptable to the individual or family but you must ask and ask for their help.

7.Ensure that victims have advocates to help navigate the systems from the moment you let them go. Most of the ethnically-identified or minority persons living in the Boston metro area lack the power and information to access the systems of care they need without assistance. In the aftermath of disaster their emotional strength and negotiating skill will likely be compromised and deficient in persisting with those elements of the care system that they need. As the clinician with immediate and live access to the client, you are in a strong position to ensure that system advocacy is made available.

Finally, this writer proposes that the most effective steps in critical incident debriefing after a WMD disaster are those which begin before the disaster occurs. Effective culturally competent preparation requires that the metropolitan area be surveyed and the communities within range of WMD targets be identified. Once this is done, community structures already in place for disaster response planning must be included in the plan and in the practices to prepare for the WMD event. Then, specific persons and positions who will be crucial in the aftermath of a terrorist event can be invited to the table to strategize and identify needed resources to effectively respond to a WMD incident. Once written, the disaster plan must be drilled and the true diversity of the community must be acknowledged. Only after such plans and practices are conducted will it be known what additional resources or systems need to be in place to conduct culturally competent critical incident debriefing. It is my proposal that this process begin immediately and that all the parties who are likely to be involved should be trained to an equivalent level.

Perhaps the most difficult aspect of WMD critical incidents is the dealing with death. This is true of the problem of assisting family members of those who have died, the task of death notification, and the process of using family members to provide information for body identification. Contrary to accepted hospital policy and current law enforcement practices, death notification should not be done by untrained persons. This is especially true of death notification when the body recovery and identification process is lengthy (as in the Oklahoma City bombing), prolonged (as in the New York World Trade Center bombing) or essentially hopeless (as in the Pan Am 103 disaster). When there are additional questions as to whether the event was a deliberate act (as in Egyptair 900) the process demands even more skill. The procedures for death notification require particular skill and practice. Improperly done, death notification can additionally traumatize victims and their families and can make them uncooperative with the investigative process. Rituals about speaking of death vary from culture to culture. It is important to pay attention to the cultural requirements for notification event though this will certainly make the death notification task more difficult and complicated for those making the notification. Hence, for example, among Muslims, notice of a daughter’s death must first be given to the male head of household before the mother is notified, even if the mother is the one who opens the door when you arrive. The Mothers Against Drunk Driving organization provides perhaps the best and most well-tested death notification training, targeting mental health professionals, medical practitioners, law enforcement officers and morticians differently as their skill sets require different information. The one thing that is common to all who suffer losses to death in terrorist incidents is the intense anger that begins almost immediately and scares all kinds of health professionals away. It is important to know how anger is expressed in each culture so that it is not overlooked or mistaken for something needing medication (the most usual mistake) as that alienates victim/survivors more than anything else. Learning how to sit with the person who may be raging at you and still be therapeutic is not intuitive in our society. Because it is the constant across cultures, it requires that we professionals learn to bear it and channel it in ways that are culturally competent. Again, appropriate training requires an identification of the cultures likely to be affected by a WMD event and then incorporation of the culture-specific information into death notification and body recovery training procedures. Most importantly, we must learn that health care workers are the least expert in managing death that affects others. In those times it is always the true peers, those who have been through such losses themselves, who can best inform us about what helps most. If these peers are not part of the trainer cadre, the training is by definition, deficient.

ANNUAL MEETING ANNOUNCEMENT

The Annual Meeting of the Network for Multicultural Training in Psychology is scheduled for Saturday, June 17, from 10 AM to 2 PM. Location to be announced (probably the Conference Room at Boston Medical Center, Harrison Campus).

The Board strongly encourages the membership to attend this Annual Meeting, at which we will welcome our newly-elected Community member, and participate in our annual program self-evaluation, measuring our progress over the year and charting our future course.

NMTP NOTES PUBLICATION SCHEDULE

At its February, 2000, meeting the NMTP Board of Directors set a regular schedule for publication of NMTP Notes, the official newsletter of the Network for Multicultural Training in Psychology, Inc.

NMTP Notes will appear at the end of the month in April, September, and January. This regular schedule allows the Newsletter Committee to plan ahead, particularly for recruitment of writers for the lead column in each issue.

Readers are encouraged to come forward to offer their services as authors for lead columns. We hope to have a draft of the lead column for the September issue by June, 2000. If interested, please let us know by emailing dtrimble@world.std.com.

Nancy Boyd-Franklin to Visit the Boston Area in September

The Annual Conference of the Massachusetts Marriage and Family Therapy Association will feature a presentation by Nancy Boyd-Franklin, author of Black Families in Therapy (Guilford, 1989). Dr. Boyd-Franklin will be presenting work from one of her two newest books, Reaching out in Family Therapy: Home-Based, School, and Community Interventions, co-authored with Brenna Hafer Bry (Guilford, 2000). This year also marks the publication in May of Boys into Men: Raising our African American Teenage Sons (Dutton), co-authored by Drs. A.J. and Nancy Boyd-Franklin.

The Conference is a one-day event, September 22, 2000, at the Crowne Plaza Hotel. It offers 6 CEUs and a full banquet luncheon. For further information, call MAMFT at 888-848-2998.

CMTP TO SURVEY ALUMNAE/I

In its self‑study for re‑accreditation this year by the American Psychological Association, the Center for Multicultural Training in Psychology made a commitment to survey its alumnae/i. CMTP hopes to learn how its graduates have fulfilled the mission of their internship, i.e., to provide culturally competent psychological services to underserved populations of color. NMTP is co‑sponsoring this effort, which is consistent with NMTP's mission to promote the culturally competent practice of psychology.

CMTP graduates will be asked where they have been working, whom they have been serving, and how they see their CMTP/MTP experience as having shaped the course of their careers. They will also be asked to reflect on their experiences as CMTP interns, what drew them to the program and how their expectations were met.

Alumnae/i will have received their survey questionnaires by the time NMTP Notes is in the mail. If you have received your questionnaire and not yet responded, please take this as your reminder to send it off today!

NMTP AT APA 2000

Drawing on their combined experience of nearly 100 years to address salient issues in the discussion, NMTP members Mabel Lam, Dyanne London, Merlin Langley, Herb Joseph, and Alice LoCicero will present a symposium at the 2000 APA Conference, "Multiracial, Multiethnic Faculty Perspectives: What Works? What Must Change?" The symposium is tentatively scheduled for Saturday, August 5, at 8 AM. Readers who will be at APA are warmly invited to attend the symposium.